Wiki Exam under anesthesia?

[b_rodgers]

Can anyone help me with a CPT code for an exam under anesthesia??

Surgery was cancelled in the OR as an airway could not be obtained. While the patient was under, doctor performed an exam of the patient's knee. We bill seperately from the hospital at which this procedure was to be performed, so we need to bill a code so that they can bill for their OR time, anesthesia, etc. But, as I've only been coding for a year and a half I haven't had this issue arise.

 

[BenCrocker]

Well first was the emergency ending of a procedure so that needs the original procedure code plus a modifier. As for the knee exam we need the documentation minus any HIPPA flags.

 

[dclark7]

If the patient was already anesthetized you would use the procedure code with a 53 modifier (discontinued procedure). If the procedure was being done in an ASC or hospital OP they can then use the procedure code with a 74 modifier (Discontinued OP Hosp/ASC procedure after the administration of anesthesia). Make sure the documentation is there to support the reason the surgery was cancelled.

 

[b_rodgers]

Here is the op note:



The patient is a **-year old female who has suffered an avulsion of her Achilles tendon insertion including a bony fragment. She was brought to the OR for surgical repair. An airway could not be obtained by anesthesia and the procedure was canceled. While the patient was sedated, attempting to get an airway, examination of her right lower extremity does show a mild defect at the posterior calcaneus at the Achilles insertion with mildly proximally displaced bony fragment. With passive ankle range of motion, this bony fragment does appear to travel with the calcaneus, the defect was not changed with passive ankle dorsiflexion. Ankle is in mild equinus passively, it was somewhat difficult to get her to even in neutral position. When the patient was waking up, she was noted to actively plantarflex her right foot and ankle. There was excellent contraction of her gastrocnemius and generated good strength of ankle plantar flexion. She was placed in a splint maintaining the foot and ankle in a mild degree of equinus and subsequently taken to recovery room in stable condition.